examination of abdomen - vydehi institute of medical … · examination of abdomen ‐ inspection...

IAP UG Teaching slides 2015-16

EXAMINATION OF ABDOMEN

ANATOMY

The abdominal cavity contains many vital organs

Peritoneum

Omentum

Mesentery

IAP UG Teaching slides 2015‐16

ANATOMY – CONTD..

QUADRANTS OF ABDOMEN

Abdomen is divided into 9 quadrants by :

2 VERTICAL LINES:from femoral arteries below to cross the costal margins close to the tips of the 9th costal cartilage on both sides.

2 HORIZONTAL LINES:sub costal and inter iliac lines.

RIGHT HYPOCHONDRIUM

Right lobe of liver Gall bladder

Right hepatic flexureOf colon

Suprarenal

EPGASTRIUM Pyloric end of stomach

DuodenumPancreas

Portion of liver

LEFT HYPOCHONDRIUM

StomachSpleen

Tail of pancreasSplenic flexure of colon

Suprarenal

RIGHT LUMBARAscending colon

Right kidneyPortion of duodenum &

Jejunum

UMBILICALOmentumMesentery

Lower part of duodenumJejunum, ileum

LEFT LUMBAR

Descending colon, Left kidney

RIGHT ILIACCaecumAppendix

Right ureterRight spermatic cord /

Right ovary

HYPOGASTRIUMIleum

Bladder

LEFT ILIACSigmoid colon

Left ureterSpermatic cord

COMMON SYMPTOMS

• Abdominal pain• Abdominal distension• Diarrhea• Constipation• Jaundice• Vomiting• Hematemesis

• Melena• Hematochezia• Hematuria• Weight loss• Pruritus

GENERAL EXAMINATION

•Look for – Pallor, Clubbing, Jaundice, Edema

Lymphadenopathy

• Hair – Depigmentation / Alopecia

• Eyes – Pallor, signs of Vitamin A deficiency,

Jaundice, K.F Ring

•Oral cavity – Glossitis, cheilitis, pallor, petechiae,

dehydration

•Limbs‐ vitamin D deficiency

•Palms‐ palmar erythema, flapping tremor

•Nails‐ Terry nails in chronic liver disease , half and half nails in chronic renal disease •Skin‐spider naevi, petechiae,scratch marks

UPPER GI EXAMINATION

• Lips‐ cheilitis, ulcers, pigmentation• Gums‐ bleeding, hypertrophy• Teeth‐ caries• Buccal mucosa‐ ulcers, thrush, petechiae palate,

fauces & tonsil.• Pharynx‐ ulcers, exudate.• Breath‐ halitosis, fetor hepaticus

PALMAR ERYTHEMA

EXAMINATION OF ABDOMEN ‐ INSPECTION

• Patient lying in supine position

• Exposed – xiphisternum to upper thigh

• Good Light

• Infant and non cooperative child – mother’s lap

• Stand on right side of the patient and examine

INSPECTION – CONT..•Shape•Normal ‐ Protuberant upto 5 years•Distended‐Generalised‐5 Fs Fluid, Flatus, Faeces, Fat, Fetus•Localized–Symmetrical ‐ Small bowel obstruction(around umbilicus)–Asymmetrical ‐ Gross enlargement of spleen, liver, ovary•Scaphoid •Starvation in older children•Diaphragmatic hernia in newborns•Distended lower abdomen ‐ Urinary retention•Flank fullness ‐ Tense ascites

INSPECTION – CONT..

•MOVEMENT– Free & equal on both sides– All quadrants move equally with respiration– Absent or diminished – Generalized peritonitis– Paradoxical movement(reverse)‐diaphragmatic paralysis– Visible peristalsis•CHPS•Distal small bowel obstruction(LADDER PATTERN)

•UMBILICUS•Normal ‐ Slightly retracted or inverted•Everted ‐ Umbilical hernia– Expansible impulse while coughing on palpation•Hernia sac – omentum /bowel /fluid•Discharge ‐ Umbilical sepsis, omphalitis•Granuloma ‐ fleshy red granulation tissue

•Striae –

–Gross stretching of skin with rupture of elastic fibres

–Recent change in size ‐ ascites, severe dieting

–Purple striae ‐ Cushing’s syndrome

•Scars – linear ‐ incisional hernia

Superficial veins –

•observe in standing posture

•Mention direction of flow

•Thin veins over the flank /over back‐Occlusion of inferior vena

•Caput medusae rare , seen in PHTN

–Blood flows from umbilicus towards periphery

PROMINENT VEINS

•Visible pulsations abdominal aorta

–a) nervous thin patients

–b) aortic aneurysms‐more obvious pulsations

•Pigmentation

–brown mottled pigmentation (erythema ab igne)

•Constant application of heat / hot water bottle

•GROINS

•Penis size, epispadias, hypospadias

•Scrotum hydrocele

•Testes enlargement, cryptorchidism

•Vulva ‐ clitoral hypertrophy, vaginal discharge

•Hernial orifices

•Inguinal lymph nodes

PROMINENT SUPERFICIAL VEINS

• Assure patient, divert child’s attention

• It’s better to keep the infant on mother’s lap

• Child relaxed, Breast feeding– best soother

• Hands – warm

• Folding of legs not needed

PALPATION

• Superficial, deep and dipping(when there is

massive ascites)

• Start in left iliac fossa

• Anticlockwise direction

• Avoid sudden poking of finger tips

• Wrist and forearm – same plane

PALPATION

FEEL THE ABDOMEN

Soft, tense, rigid, doughy ( TB)

Tense and glistening – tense ascites

Floating abdomen – prune belly syndrome

Edema of abdominal wall – pinching for 5 sec.

Tenderness‐Localized OR Generalized

PALPATION

FEEL FOR

Left kidney

Spleen

Right kidney

Urinary bladder

Aorta and para‐aortic glands

Femoral vessels

Groins

External genitalia

PALPATION

Rapid method is to palpate liver and spleen which are enlarged commonly and then to palpate

other organs

SPLEEN

Normal – not palpable

Tip can be palpated till 3 months of age

Palpable 2 – 3 times its usual size

Enlargement occurs in the superior & posterior

direction downward towards RIF

Method of palpation:

• Conventional – supine position

Place flat of the left hand over lowermost ribcage

poster‐laterally and right hand beneath the costal

margin. If not palpable – right lateral position

•Hooking method

SPLEEN (CONT…)

SPLENOMEGALY

•Describe size, surface, consistency, tenderness and

distance from the costal margin. Look for splenic notch

•Mild < 3cms

•Moderate 3 – 7cms (upto umbilicus in midline)

•massive > 7cms

SPLENOMEGALY

•Firm swelling with smooth, rounded border

•Moves down on inspiration

•Splenic notch may be palpable

•Upper border cannot be felt(can’t get above it)

•Not bimanually palpable

•Band of colonic resonance anterior to an enlarged kidney

SPLENOMEGALY

Causes

•SOFT IMN, Typhoid

•FIRM Malaria, PHT, Leukemia

•Start from the right iliac fossa and ascends upwards to right

costal margin

•Place right hand below and parallel to the costal margin

•Ask the patient to breathe in deeply and at the height of

inspiration press the fingers firmly inwards and upwards

Normal: 2cms upto 5 years, thereafter 1cm sharp, regular border•Size: so many cms below RCM•Surface: smooth / irregular•Border: rounded / sharp•Tenderness: +\‐•Consistency: Soft – CCF, Infective Hepatitis

Firm – Obstructive JaundiceHard – Cirrhosis

•Pulsatility:•Liver span:

Span: Normal: from 5th ICS in right MCL to the point of dullness at lower margin

Birth 5.6 to 5.9 cm2 months 5 cm1year 6 cm 2year 6.5 cm3year 7 cm4year 7.5 cm5year 8 cm6 – 12 year 9 cm

• Pulsatile: Tricuspid Regurgitation

• Tenderness: CCF, Infective Hepatitis

• CCF: Soft, smooth, tender

– Cirrhosis: Hard, irregular, painless

– Advanced cirrhosis: shrunken liver

– Rapid shrinkage: Acute hepatic necrosis

CAUSES OF HEPATOMEGALY

•Congestion

•Cirrhosis

•Hepatitis

•Neoplasm

GROSS HEPATOSPLENOMEGALY

GALL BLADDER

•Normal: Not palpable•Palpate just lateral to the edge of rectus abdominis near the tip of the 9th costal cartilage•Enlargement: Uncommon in children– Pear shaped swelling beneath the centre of undersurface of liver– Cystic in consistency– Freely mobile from side to side

GALL BLADDER

•Murphy’s sign: Child is asked to take breath while

maintaining constant pressure over the gall bladder

region. Gall bladder touches the fingers and the child

catches his breath

•Tenderness: Cholecystitis with or without cholelithiasis

KIDNEYS

Bimanual palpation

Right kidney:

•Right hand in the right lumbar region anteriorly, left hand

posteriorly in the right loin.

•Push forwards with the left hand, ask the patient to take a deep

breath in and press the right hand upwards and inwards

KIDNEYS

Left kidney

•Right hand anteriorly in left lumbar region, left hand posteriorly in the

left loin

•Press left hand forwards, right hand backward, upward and inward

•Ballotment: Push the kidney back & forward between two hands

•Assess the size, surface & consistency of a palpable kidney.

KIDNEYS

KIDNEYS•Enlarged Kidneys: •Unilateral •Compensatory hypertrophy in renal agenesis, hypoplasia, atrophy•Hydronephrosis•Renal tumor•Bilateral•Polycystic kidneys•Amyloidosis•Rarely two kidneys join at lower pole and may be palpable Horse‐shoe Kidney

IAP UG Teaching slides 2015-16 49

URINARY BLADDER

•Smooth, firm, regular, oval in supra‐pubic region

•Lower border not made out

PERCUSSION

•To detect the boundaries of abdominal organs and masses

•Done from resonant area to dull area

•Percuss

–lightly for superficial structures

•e.g.: for lower border of liver

–firmly for deeply seated structures

•e.g.: for upper border of liver, Bladder

PERCUSSION

Liver‐Start from the 2nd right intercostal space.

•Go vertically down

•Dull note at the 5th right intercostal space in the midclavicular

line,7th right intercostal space in the midaxillary line and 9th

intercostal space in the scapular line is the normal upper border

•This dullness extends down to the lower border found at or just

below the right costal margin

•Start from below upwards to detect lower border

PERCUSSION

Spleen

•Traube’s space is more sensitive for splenic enlargement

•Boundaries‐ 6th rib superiorly, left midaxillary line laterally and

left costal margin inferiorly

•During normal breathing the space is percussed out from the

medial to lateral, yielding resonant note.

PERCUSSION ‐ASCITES

•1000‐1500 ml‐flank dullness is percussed, if flank dullness present

look for shifting dullness

•Patient in supine position & percuss from center of the abdomen to

the flank until a dull note is obtained.

•Keep the fingers in place as the patient rolls on to the other side

•Pause for at least 30 secs. Ascites is identified if the note becomes

resonant & confirmed by obtaining a dull note while percussing back

towards the umbilicus.

Shifting dullness

PERCUSSION

•Place a detecting hand on the person’s flank and flick the skin of

the abdominal wall over the other flank using thumb and fore‐finger.

•If a thrill or impulse is felt, repeat the procedure with the patient’s

right hand placed on the abdomen along the midline sagittal plane

to dampen any possible thrill transmitted via the abdominal wall

•Fluid thrill Massive ascites

Fluid thrill

PERCUSSION

•Knee elbow position to ensure gravitation of fluid

•The chest piece of stethoscope is placed over the mid

abdomen & abdominal wall is gently tapped with index

finger moving from one flank towards the center

•Puddle sound audible – minimal effusion(150ml)

Puddle sign

PERCUSSION

Renal angle percussion

•The renal angle bounded by the 12th rib superiorly

and the lateral border of erector spinae

•Normally resonant due to colonic gas

•Dull in renal enlargement

•Tender in renal abscess

AUSCULTATION

•Bowel sounds – normally best heard a little to the right or left of umbilicus•High pitched bowel sounds – Diarrhea, Empty bowel, Intestinal obstruction•Absent bowel sounds – Paralytic ileus, late intestinal obstruction, Peritonitis•Bowel sounds not audible in massive ascites because of mechanical obstruction•Borborygmi: Increased frequency & intensity of bowel sounds (gurgling sounds) audible to unaided ear.

AUSCULTATIONFriction rubs:•Liver – Hepatic tumor or infection (Perihepatitis)•Spleen – Splenic Infarct ( IMN, Malaria, SCA) PerisplenitisBruit:•Kidney – Renal artery stenosis, Renal AV fistula, •Venacaval thrombosis•Liver: Malignancy (Hemangioma, Hepatoma)•Arterial: Aortic, Mesenteric (narrowed or partially occluded)•Venous Hum: Portal HTN

ANUS & RECTUM

•Perianal erythema Lactose Intolerance

•Polyps red & pedunculated

•Tags & Fissures

•Hemorrhoids Dark red

•Prolapse rectum Malnutrition, Trichuriasis

•Perianal fistula Crohn’s disease

ANUS & RECTUM

•Rectal examination:

–Hirschsprung’s disease – empty rectum

–Intussusception

•Abdominal mass extending to pelvis

–Rectal bleeding

–Urethral stone

OTHER SYSTEMS

•CVS:

•Cardiomegaly: Anemia

•Microcardia: Kwashiorkor

OTHER SYSTEMS

•RS:

•Pleural effusion: Cirrhosis, Nephrotic Syndrome

•Bowel sounds in Chest: Diaphragmatic Hernia

OTHER SYSTEMS

•CNS:

•Signs of Hepatic encephalopathy

•Wilson’s disease

•Reye’s syndrome

THANK YOU

examination of abdomen - vydehi institute of medical … · examination of abdomen ‐ inspection...

Documents

clinical examination of abdomen medicine

the abdomen 1. anatomy & physiology 2. history 3....

the abdomen clinical examination of the abdomen anterior...

physical examination abdomen. the abdomen is a large oval...

physical examination abdomen

introduction the acute abdomen · • vomiting x 2 since...

abdomen examination

vydehi institute of medical scinces research · pdf...

1 vydehi institute of medical sciences research centre,...

vydehi institute of medical sciences and research … ·...

acute pain abdomen , clinical examination and reaching for a...

vydehi institute of medical sciences and research centre ·...

vydehi institute of medical sciences & research … ·...

examination of the abdomen - جامعة آل...

clinical profile of non-traumatic acute abdomen at a … ·...

station 1 - abdomen steps of examination (1) approach …

examination of the abdomen - elpaso.ttuhsc.edu · learning...

clinical examination of the gi tract and abdomen [recovered]...

dr. olly examination of the abdomen

thorax abdomen examination